Playing the pregnancy odds

MONTEBELLO, Calif. —

Pictures of children, his trophies, decorate Dr. Tien Chiu's office.

Three smiling siblings, he said, were the first Japanese-American triplets conceived in a lab. The robust-looking quadruplets were born after sperm was injected into their mother's eggs with a needle.

To the couples who turned to Chiu, the babies were special gifts. To the government and fertility industry, though, such large multiple births have begun to look like breakdowns in the system.

The issue has taken on renewed scrutiny since a California woman, Nadya Suleman, who already had six children conceived through in vitro procedures, gave birth to octuplets near Montebello last month.

Nearly one-third of in vitro births involve twins or more. The government, along with professional associations, have been pushing fertility doctors to reduce that number, citing the disastrous health consequences that sometimes come with multiple births: infant mortality, low birth weights, long-term disabilities and thousands of dollars in medical care.

Embryo guidelines

The American Society for Reproductive Medicine, the association of fertility doctors, even adopted guidelines in 2008 encouraging the transfer of only one embryo for women younger than 35, and no more than two, except in extraordinary circumstances.

The guidelines for older women allow up to five.

But unlike some other countries, the United States has no laws to enforce those guidelines. The Centers for Disease Control and Prevention (CDC) has a surveillance system that collects data on fertility clinics, but reporting is voluntary.

As a result, experts said many doctors are implanting too many embryos to increase the chance of pregnancy. Only 11 percent of in vitro procedures in the U.S. involve single embryos, according to 2006 data from the CDC.

But the 2008 guidelines say that in many cases, it is healthier to implant only one, even if it means the process is repeated, because of the risk of multiple births.

In the case of Suleman, the California Medical Board said it was investigating her doctor, Michael Kamrava, to determine whether accepted standards of medical practice were violated. In an interview with NBC News, Suleman, 33, said Kamrava had implanted six embryos, and two of them had divided into twins, resulting in eight babies.

"She wanted to have many, many babies," said Chiu, who added he had formerly treated Suleman but declined to give details.

One cycle of in vitro fertilization costs about $12,000. Women not successful the first time often try again and again. Because the technology is often not covered by insurance, doctors said they are constantly urged by patients to implant extra embryos.

One woman, a nurse who could afford only one try, pressured Chiu to transfer eight embryos. "I said under one condition," Chiu remembered. "I made her sign an agreement that she would do selective reduction."

That agreement, to remove some of the embryos if they lived, was likely unenforceable. But in the end it worked out. Only one embryo survived, and the woman gave birth to a healthy child.

Chiu said a situation in which he would implant eight embryos would be a rarity, adding, "I don't think any doctor would try to make a multiple pregnancy."

Beverly Hills clinic

Suleman now has 14 children through in vitro fertilization. In the NBC interview, she identified her clinic as the West Coast IVF Clinic in Beverly Hills, run by Kamrava. He did not return telephone calls seeking comment.

Suleman said in the interview that she was aware of the risks of multiple births but wanted to use all the embryos available to her.

The treatment involves removing eggs from a woman's ovaries, combining them with sperm in a laboratory and implanting the resulting embryos in the woman's uterus. In some cases the eggs come from a donor. The number of embryos implanted is often a judgment call and can make a big difference in a pregnancy's outcome.

"Every single decision we make about embryo transfers is a tough one, because we don't have a crystal ball," said Dr. Jeffrey Steinberg, who runs the Fertility Institutes, a group of fertility clinics in Southern California.

The industry has doubled in size in the decade since the CDC started collecting data in 1996. That year, 64,681 procedures were performed in 330 clinics. At last count, the number was up to 134,260 and there were more than 483 clinics.

More than 50,000 children a year are born as a result of in vitro fertilization in this country. Nationwide, it is a more than $1 billion business.

The percentage of births involving triplets or more declined to 2 percent in 2006, from 7 percent in 1996. The American Society for Reproductive Medicine points to that as among its successes.

Dr. Daniel Potter, medical director of Huntington Reproductive Center, also in Southern California, said the onus remained on the doctor, regardless of the patient's wishes. "If someone came in and wanted to transfer six embryos in a situation like we're talking about, we have an obligation to protect the patient and not let the patient do things that are unreasonable," Potter said.

Dr. David Hill, an embryologist who directs the laboratory at the ART Reproductive Center, an in vitro clinic in Beverly Hills, said the United States had retained a laissez-faire stance toward in vitro procedures instead of regulating the process.

But comparing the U.S. industry to Europe's, for example, may be unfair because some countries cap costs for in vitro fertilization or require coverage by health programs, removing the financial incentive by women to push for pregnancy on the first try.

"The point is, there was greater pressure for U.S. clinics to deliver, no pun intended, on the first try, so they would put back more embryos, and hopefully one of them would take," Hill said.

The fewer, the better

More recently, methods of producing and selecting embryos have improved, removing some of the incentive to implant a high number. Success rates are higher when two or more embryos are implanted, but recent statistics suggest the likelihood of having a child is better with two embryos than with three.

Even so, when patients hear the pros and cons, they often push for multiple embryos, Hill said. "I can't tell you how many patients will come in, and when we explain the risks of twins, they say, 'Hey, bring it on.' They're desperate to get a family going."

Part of the reason doctors might acquiesce could be the fierce competition in the industry. California has more doctors performing in vitro fertilization than any other state, with many concentrated in the Los Angeles area.

The competition means sales pitches are not unusual.

The Huntington Reproductive Center offers a refund for some women. No pregnancy? You get 90 percent of your money back.

Want to predict the sex of your baby? That is 99.99 percent guaranteed at the Fertility Institutes.

Kamrava, Suleman's doctor, had previously raised eyebrows in the industry by advocating a procedure called "SEED": subendometrial embryo delivery, in which he said he could increase pregnancy rates by using a plastic tube to insert embryos under the lining of the uterus for maturation, rather than in the uterus. The procedure's value was never scientifically proved, according to Potter.

Several Southern California doctors disclosed embryo-transfer rates significantly higher than the national norm, according to the CDC data. A look at Kamrava's statistics in 2006, for example, might have raised red flags.

High transfer rate

They revealed his clinic had one of the nation's highest rates of embryo transfer in younger women: 3.5 versus a national average of 2.3. Such high rates sometimes indicate a doctor is being too aggressive in trying to raise the number of pregnancies.

In Kamrava's case, however, those numbers were among the lowest in the nation. Of 56 procedures performed by his clinic in 2006, only two resulted in women giving birth, one to a single baby and the other to twins.

The twins may have been the set born to Suleman that year.